Provider Demographics
NPI:1427096239
Name:NOVAK, JAN (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:NOVAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 GRIDER ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3021
Mailing Address - Country:US
Mailing Address - Phone:716-898-3391
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109754207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2306955OtherINDEPENDENT HEALTH
NY000507825003OtherHEALTH NOW
NY00626811Medicaid
NY00010128301OtherEXCELLUS UNIVERA
NY000507825003OtherHEALTH NOW
NY00626811Medicaid
441101384Medicare PIN